Payroll Direct Deposit Authorization Agreement Form
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1NEW YORK CITY HEALTH AND HOSPITALS CORPORATION
PAYROLL DIRECT DEPOSIT AUTHORIZATION AGREEMENT
SECTION 1: EMPLOYEE INFORMATION
INSTRUCTIONS:
If you do not have a garnishment or wage assignment deducted
NAME:
from your wages and are otherwise eligible for direct deposit,
complete this form as described below:
LAST
FIRST
FACILITY:
-For new enrollment………..…………..fill in sections 1, 2, and 4.
EMPLOYEE ID NUMBER
WORK PHONE NUMBER
-For bank and/or account changes…..fill in sections 1, 3, and 4.
-For termination of service……....…….fill in sections 1 and 5.
_______/_______/_______ ( _____) _____-_______
SECTION 2: NEW ENROLLMENT (Attach a voided check/deposit slip or copy of savings account statement)
ABA NUMBER
(9 digit number that appears on the bottom of your
check or deposit slip just preceding your account #.)
ACCOUNT NUMBER
ACCOUNT TYPE
SAVINGS
CHECKING
SECTION 3: CHANGE OF:
BANK
ACCOUNT NUMBER
ACCOUNT TYPE
(CHECK ALL BOXES WHICH APPLY)
(Attach a voided check/deposit slip or copy of savings account statement & fill in the boxes below.)
ABA NUMBER
(9 digit number that appears on the bottom of your
check or deposit slip just preceding your account #.)
ACCOUNT NUMBER
ACCOUNT TYPE
SAVINGS
CHECKING
SECTION 4: EMPLOYEE AUTHORIZATION
I hereby authorize the New York City Health and Hospitals Corporation to deposit my net pay
directly into my checking or savings account shown above and initiate (if necessary) debit
entries and adjustments for any credit entries made in error to this account. I agree that this service
authorization will remain in effect until I provide a written request to terminate this service, or
a garnishment or wage assignment is placed on my wages, or when I terminate employment.
SIGNATURE: ____________________________________
DATE: ____________
SECTION 5: TERMINATION OF SERVICE REQUEST
I hereby authorize the New York City Health and Hospitals Corporation to terminate my payroll direct
deposit authorization agreement as soon as administratively possible.
SIGNATURE: ____________________________________
DATE: ____________
FOR FACILITY PAYROLL DEPARTMENT USE ONLY
ENROLLMENT REJECTION:
ENTRY INFORMATION:
NON-ELIGIBILITY
ENTERED BY: ____________________ DATE: ___________
Garnishment
Pre-note reject- List reason below
Pre-note payroll _____/_____/_____ Eff. Payroll _____/____/____
Family Court Order
Other – List reason below
_____________________
Informed employee of rejection
Reason:
_____________________
Name: ____________________ Date: __________
as of 5/28/2010
direct deposit form
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